Drugs, AIDS, and Harm Reduction

Drugs, AIDS, and Harm Reduction HOW TO SLOW THE HIV EPIDEMIC IN EASTERN EUROPE AND THE FORMER SOVIET UNION Drugs, AIDS, and Harm Reduction HOW TO SLOW THE HIV EPIDEMIC IN EASTERN EUROPE AND THE FORMER SOVIET UNION IHRD International Harm Reduction Development OPEN SOCIETY INSTITUTE © 2001 Open Society Institute The International Harm Reduction Development (IHRD) program of the Open Society Institute supports local, national, and regional initiatives in Central and Eastern Europe, the Russian Federation, and Central Asia that address drug problems through innovative measures based on the philosophy of harm reduction. Harm reduction programs attempt to diminish the individual and social harms associated with drug use—especially the risk of HIV infection. Harm reduction encompasses a wide range of drug user services, including needle and syringe exchange, methadone treatment, health education, medical referrals, and support services. For more information, contact: International Harm Reduction Development program Open Society Institute 400 West 59th Street New York, NY 10019 USA Tel: 212.548.0677 Fax: 212.428.4617 E-mail: [email protected] www.soros.org/harm-reduction IHRD Kasia Malinowska-Sempruch, Director Sue Simon, Associate Director Anna Moshkova, Program Officer Jennifer Traska Gibson, Program Coordinator Matt Curtis, Program Coordinator Magdelena Sklarski, Training Coordinator Drugs, AIDS, and Harm Reduction was produced by IHRD and OSI’s Communications Office with the editorial help of John Heller, Jennifer Lisle, Jeff Hoover, Rebecca Foster, and Daniel Wolfe. Photography credits: © Jacqueline Mia Foster: front and back covers, pages 24, 32-33. © John Ranard: pages 4-5, 7, 8-9, 10, 13, 16-17, 18-19, 21, 28, 70-71. Design: Jeanne Criscola/Criscola Design Printing: Herlin Press, Inc. CONTENTS 6 FOREWORD: REDUCING HARM IS A REALISTIC GOAL by Kasia Malinowska-Sempruch 8 DRUGS, AIDS, AND HARM REDUCTION 10 I. THE CRISIS: RISING DRUG USE AND HIV IN EASTERN EUROPE 18 II. THE BETTER ALTERNATIVE: HARM REDUCTION PROGRAMS 24 III. OSI’S LEADERSHIP IN THE HARM REDUCTION MOVEMENT 30 AFTERWORD: HARM REDUCTION PROGRAMS EXEMPLIFY OPEN SOCIETY VALUES by Aryeh Neier 32 DIRECTORY: HARM REDUCTION PROGRAMS IN EASTERN EUROPE AND THE FORMER SOVIET UNION 72 NOTES Traditional, authoritarian methods of drug control do not stem the tide of drug use or the social and health harms associated with it. By contrast, harm reduction methods work. FOREWORD: REDUCING HARM IS A REALISTIC GOAL As many as four million people in Eastern Europe and the former Soviet Union are injecting drug users at great risk of becoming infected with HIV from shared injection equipment. We know that traditional, authoritarian methods of drug control do not stem the tide of drug use or the social and health harms associated with it. By contrast, harm reduction methods work. Harm reduction, a nonjudgmental, humane public health response to drug use, is premised on the conviction that it is more productive to integrate drug users into society than to separate them. It also assumes that when drug users are provided the opportunity, they make lifestyle changes that improve their overall health. The realistic goal of reducing the harms caused by drug use replaces the unrealistic goal of eliminating drug use altogether. Harm reduction, practiced for many years in Western Europe, North America, and Australia, has proven effective. Harm reduction in Eastern Europe and the former Soviet Union, however, has met with opposition from people who see it as an alien Western methodology that inappropriately slipped through the borders that started opening in the late 1980s. By moving the philosophy and practice beyond its origins, the International Harm Reduction Development (IHRD) program and its partners have established that harm reduction can indeed be adapted to the needs of this particular region. IHRD, a program of the Open Society Institute, has supported harm reduction projects that are scrupulously designed to respond to the social and cultural realities of the populations they serve. The projects described in this publication reflect the heterogeneity of the region. The people who developed these projects to fit into the social and cultural landscapes are training others, reinforcing indigenous priorities. Local governments are beginning to take notice and to respect the validity of these activities. The practices of harm reduction are taking hold. 6 IHRD To slow the HIV epidemic, replication of these harm reduction projects must outpace the proliferation of HIV. This may still be possible since the epidemic is in its early stages, but it can only happen if communities, politicians, law enforcement, and all citizens recognize the gravity of the crisis and the urgency of responding. We are proud of the pilot projects OSI has funded. We hope that the good sense behind their activities, the effectiveness of their results, and the courage of the people who run them will inspire others in the region to replicate their efforts—quickly and comprehensively. Kasia Malinowska-Sempruch Director International Harm Reduction Development program Open Society Institute HIV-positive babies in a general hospital. FOREWORD 7 DRUGS, AIDS, AND HARM REDUCTION An HIV patient's bed in the hallway of a hospital. Health care systems in the region remain in poor shape to cope with the twin epidemics of drug use and HIV infection. 8 IHRD The global HIV epidemic is spreading through the countries of Eastern Europe and the former Soviet Union in tandem with a steep rise in injection drug use. In parts of the region, the HIV infection rate is increasing faster than anywhere else in the world. Despite such alarming statistics, injecting drug users (IDUs), who are among the most at risk of HIV infection, are not receiving the attention and care they deserve—largely because prejudice against them hinders efforts to establish appropriate services and policies, such as harm reduction strategies, that could help prevent HIV infection. Experience in North America, Australia, Western Europe, and elsewhere shows that needle/syringe exchanges and other harm reduction approaches are effective not only in diminishing risks to IDUs but in curbing the HIV epidemic overall. The International Harm Reduction Development (IHRD) program of the Open Society Institute, in partnership with Soros foundations in Eastern Europe and the former Soviet Union, has supported 162 harm reduction programs at 128 organizations to provide drug users with access to clean needles/syringes, substitution drug therapies, sexual health education, and a variety of social care services. More support from governments and funders is desperately needed to sustain and expand these activities. Among other necessary developments, strong political leadership is critical to overcoming public resistance to helping homeless youth, sex workers, prisoners, and other often marginalized people who make up a disproportionately high number of IDUs. The urgency is to act quickly in Eastern Europe and the former Soviet Union before the HIV epidemic spreads further and thousands more begin to die. THE CRISIS 9 I THE CRISIS: RISING DRUG USE AND HIV IN EASTERN EUROPE The main factor exposing injecting drug users to the risk of HIV infection is the sharing of contaminated injection equipment. 10 IHRD STARK FIGURES: THE STEEPEST HIV CURVE IN THE WORLD Increasingly large numbers of people in Eastern Europe and the former Soviet Union are injecting illicit drugs. Estimates at the end of 2000 put the number between 2.3 million and 4 million IDUs in the region. In Russia alone, estimates range from 1 million to 2.5 million. The rise is particularly rapid in many urban areas. For example, out of 32,000 young people between 15 and 29 years of age in the Kazakh city of Temirtau, at least 3,000 are believed to be IDUs.1 HIV infection shadows injecting drug use. In 1995, the number of HIV infections in Eastern Europe and the former Soviet Union was estimated at below 30,000. At the end of 1999, the number for the region had climbed to 420,000, and the United Nations announced that the newly independent states had the steepest HIV infection curve in the world.2 A year later, at the end of 2000, the number of HIV infections in Eastern Europe and the former Soviet Union had almost doubled, to 700,000.3 Despite the UN’s warnings, however, few governments or international funders have moved to mobilize sufficient resources to respond to the disease in the region. Russia has been particularly hard hit by the epidemic. “In one year, more people have become infected with HIV in Russia than all previous years combined,” Peter Piot, executive director of UNAIDS, said in November 2000.4 At that time, UNAIDS put the number of HIV-positive people in Russia at 300,0005 by the end of 2000. Vadim Pokrovsky, head of Russia’s Center on AIDS Control and Prevention, believes the epidemic in his country is even more severe. In April 2001, he estimated that there were 500,000 HIV-positive people in Russia at the end of 2000 and that the number would rise to 1 million by the end of 2001.6 With a huge majority of the region’s HIV cases traceable to injecting drug use (80 percent of the cases in the newly independent states, for example), there is hope that bold measures will staunch the epidemic’s spread.7 But the window of opportunity to make a difference is closing. Unless comprehensive harm reduction programs are adopted throughout the region, more and more people who inject drugs will contract HIV. And, as the percentage of cases THE CRISIS 11 resulting from sexual contact grows (often systems have moved in the other direction, placing transmitted unknowingly by IDUs), HIV responsibility for health care in the hands of consumers infection will spread throughout the and putting poor people and marginalized groups at great risk.

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